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Secretary of Veterans' Affairs

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Secretary of Veterans' Affairs June 24, 2020 The Honorable Robert Wilkie Secretary U.S. Department of Veterans Affairs 810 Vermont Avenue NW, Room 1063B Washington, DC 20420 Dear Secretary Wilkie: The undersigned medical associations and medical specialty societies are writing to register serious concerns with the Health Care Professional Practice in VA Memorandum (Memorandum) issued by the Office of the Under Secretary of Health on April 21, 2020, and underlying Directive 1899 (Directive). The undersigned organizations urge the Secretary to amend Directive 1899 as it relates to allowing non-physician healthcare professionals in 32 specialties to operate “within the full scope of their license, registration, or certification” and rescind the Memorandum as it relates to encouraging all VA medical facilities to allow CRNAs to practice without physician oversight during the national health emergency. The undersigned organizations are very concerned Directive 1899 preempts state scope of practice laws. Directive 1899 memorializes U.S. Department of Veterans Affairs (VA) policy allowing VA health care professionals to practice across state lines and establishes new policy allowing VA health care professionals to operate within the full scope of their license, registration, or certification. This combination in effect circumvents state scope of practice laws for the 32 health care professionals defined in the directive. Such a far-reaching expansion is overly broad, unnecessary and threatens the health and safety of patients within the VA system. As state scope of practice laws vary across these professions and across states, we urge the Secretary to amend the directive to defer to state scope of practice laws, similar to the language related to psychologists in Appendix B of the Directive. The undersigned organizations also encourage the Secretary to rescind the Memorandum as it relates to encouraging all VA medical facilities to allow CRNAs to practice without physician oversight during the national health emergency. Throughout the coronavirus pandemic physicians, nurses, and the entire health care community have been working side-by-side caring for patients and saving lives. The AMA supports these temporary emergency efforts that allow physicians to practice across state lines to quickly expand the physician workforce in areas of need. Our success as a nation in flattening the curve of this pandemic is due in no small part to this shared focus and shared responsibility. Now more than ever, we need health care professionals working together as part of physician-led health care teams--not in silos. Therefore, it is deeply troubling, that the VA is directing all VA medical facilities to amend their by-laws to allow CRNAs to practice without physician oversight. Like most healthcare systems, the pandemic has forced the VA to reassess how it uses human resources. Non-essential surgeries have been cancelled during the pandemic, giving the VA Honorable Robert Wilke June 24, 2019 Page 2 flexibility to deploy physicians and other healthcare professionals where the need is greatest. As such, there are more than enough physicians to provide care and oversight during this time. Thus, removing physician oversight requirements of CRNAs at the VA is overly broad, inconsistent with the situation as it is unfolding outside of the VA, and unnecessary to address the immediate needs raised during the COVID-19 pandemic. This action by the VA will only serve to disrupt continuity of care and cause confusion among health care teams and their patients. It was this knowledge that prompted West Virginia Governor James C. Justice, II to promptly issue Executive Order No. 12-20, on March 26, 2020, reinstating physician supervision of CRNAs during the public health emergency.1 As such, it is unclear why the VA has deemed the expansion at issue as necessary. Such measures are not necessary to improve patient access to care and take away from a higher quality team-based approach. More importantly, a lack of proper oversight threatens the health and safety of veterans and their families. For all the reasons outlined above, the undersigned organizations strongly urge you to amend Directive 1899 and rescind the Memorandum. Such broad expansions of scope of practice deserve thoughtful discourse where all sides are allowed to be heard and all available evidence is considered. Thank you in advance for your attention to this important matter. Sincerely, American Medical Association AMDA - The Society for Post-Acute and Long-Term Care Medicine American Academy of Allergy, Asthma & Immunology American Academy of Dermatology Association American Academy of Emergency Medicine American Academy of Family Physicians American Academy of Neurology American Academy of Ophthalmology American Academy of Physical Medicine and Rehabilitation American Association for Hand Surgery American Association of Hip and Knee Surgeons American Association of Neurological Surgeons American Association of Orthopaedic Surgeons American College of Emergency Physicians American College of Medical Genetics and Genomics American College of Osteopathic Surgeons American College of Physicians American College of Radiology American College of Surgeons American Medical Women’s Association 1 Despite this, West Virginia has been incorrectly included on the VA list of states that have temporarily suspended licensure limitations for CRNAs. Honorable Robert Wilke June 24, 2019 Page 3 American Orthopaedic Foot & Ankle Society American Osteopathic Association American Psychiatric Association American Rhinologic Society American Society for Clinical Pathology American Society for Dermatologic Surgery Association American Society for Gastrointestinal Endoscopy American Society for Laser Medicine and Surgery American Society of Anesthesiologists American Society of Cataract & Refractive Surgery American Society of Echocardiography American Society of General Surgeons American Society of Plastic Surgeons American Urological Association Association of Academic Physiatrists Association of University Radiologists College of American Pathologists Congress of Neurological Surgeons International Society for the Advancement Spine Surgery National Association of Medical Examiners Society for Cardiovascular Angiography and Interventions Society of Interventional Radiology Spine Intervention Society Medical Association of the State of Alabama Arizona Medical Association Arkansas Medical Society California Medical Association Colorado Medical Society Connecticut State Medical Society Medical Society of Delaware Medical Society of the District of Columbia Florida Medical Association Inc Medical Association of Georgia Hawaii Medical Association Idaho Medical Association Illinois State Medical Society Indiana State Medical Association Iowa Medical Society Kentucky Medical Association Louisiana State Medical Society Maine Medical Association MedChi, The Maryland State Medical Society Massachusetts Medical Society Honorable Robert Wilke June 24, 2019 Page 4 Michigan State Medical Society Minnesota Medical Association Mississippi State Medical Association Missouri State Medical Association Montana Medical Association Nebraska Medical Association Nevada State Medical Association New Hampshire Medical Society Medical Society of New Jersey New Mexico Medical Society Medical Society of the State of New York North Dakota Medical Association Ohio State Medical Association Oklahoma State Medical Association Pennsylvania Medical Society Rhode Island Medical Society South Carolina Medical Association South Dakota State Medical Association Tennessee Medical Association Texas Medical Association Utah Medical Association Vermont Medical Society Medical Society of Virginia Washington State Medical Association Wisconsin Medical Society Wyoming Medical Society CC: Richard Stone, MD, Executive in Charge, Veterans Health Administration .
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